This document discusses various tools used to assess pain. It describes unidimensional and multidimensional instruments for assessing pain intensity, including verbal rating scales, numerical rating scales, and visual analog scales. It also discusses screening tools for neuropathic pain such as the Leeds Assessment of Neuropathic Symptoms and Signs and the Neuropathic Pain Questionnaire. Finally, it outlines scales for assessing psychological factors associated with pain, such as the Beck Depression Inventory, Hamilton Depression Scale, and Hospital Anxiety and Depression Scale.

1. Dr. Ravi Shankar Sharma
Fellow(Daradia )

2. Three keystones:-
 History
 Clinical examination
 Investigations(diagnostic interventions/diagnostic
nerve block)

3. A: Quantity or severity or intensity of pain
 Numerous pain scales for practical assessment of pain intensity in
clinical studies have been developed
Instruments for intensity assessment:
Unidimensional Multi dimensional
1.Verbal rating scales 1.Mc Gill pain questionnaire
2.Binary scale 2. Brief pain inventory
3.Numerical rating scale 3. West Haven –Yale multidimensional
4.Faces rating scale pain inventory
5.Visual analog scale 4. Medical outcome study 36 item short
form(SF-36)health survey

4. Unidimensional instruments:
1.Verbal rating scales(VRS)
 Response is noted as None, mild ,moderate or severe
 Advantage-short, easy to express and understand
especially in elderly
 Disadvantage-lack of reproducibility
2. The binary scale
e.g. do you have a 60% reduction in your pain?
“Yes/no”
 Advantage-short, easy to express and understand.
 Disadvantage-lack of reproducibility

5. 3.The numerical rating scale(NRS)-
 Most commonly used
 A reduction of 30% or 2 points and more from baseline-
positive response for Rx.
 Disadvantage –Digital scale reduces the capacity to
detect subtle changes

6. 4. The faces rating scale (Wong-Baker)
 Patient is asked to point at various facial expressions
ranging from a smiling face to an extremely unhappy
face.
 Advantage :- when the communication with the patient
is difficult as with the pediatric and deaf and dumb
patients

7. 5. The visual analog scale (VAS)
 10 cm horizontal line
 the distance from no pain to the patient mark indicates the
severity of pain numerically
 Advantage-simple, efficient , valid, and minimally intrusive
 Disadvantage-more time consuming than others & some
difficulty in understanding in elderly

8. Multi dimensional instruments:
1.The Mc Gill pain questionnaire(MPQ)- Melzack and Torgerson-
1971
 Defines pain in 3 major dimensions by 20 set of descriptive words
divided as-
a. 10 sets describes sensory- discriminative (nociceptive pathway)
b. 5 sets describe motivational –affective (reticular and limbic
structure)
c. 1 set describe cognitive evaluative
d. 4 sets describe miscellaneous dimensions.
Advantage- helps in diagnosis as choice of descriptive words that
characterize the pain correlates well with pain syndromes.
Disadvantage – high level of anxiety and psychological
disturbances can obscure the MPQ discriminative capacity.

10. 2. Brief pain inventory(BPI):
Measures both the intensity of pain (sensory dimension)
and its interference with the patient life(reactive
dimension)
 Advantage-
 valid for cancer pain and various pain syndromes
 shows good sensitivity to T/t.
 helps in comparing international trials with different
culture and population

11. Memorial Pain Assessment Card
 Pain assessment tool for cancer patients
 Consists of three separate visual analog scales and
assesses pain , pain relief and mood.
 Card includes a set of adjectives to describe pain
intensity

12. B:Assesment of Quality or nature of pain
 Important for diagnosing the nature or character of pain
whether it is nociceptive or neuropathic or a mixed
nature.
Screening tools for Neuropathic pain:
1.Leeds assesment of neuropathic symptoms and signs:
 It has two components in form of symptoms and signs
 For Each item binary response is noted-yes/no
 Scores ≥12/24 indicates pain is likely to be neuropathic

13. Use is limited- because of need for clinical
examination and pinprick testing

14. 2. Neuropathic pain questionnaire(NPQ)
 The NPQ is a self questionnaire consisting of
12 items :
10 related to sensations or sensory responses
 2 related to affect
Each item is scored on a scale of 0(no pain ) to
100(worst possible pain)

15. NPQ Questionnaire:

16. 3.Douleur Neuropathique en 4(DN 4) questions:
Consists of 7 items related to symptoms and 3 items
related to physical examination
 Each item is scored 1(yes) or 0(no)
 sum of all ten items is taken as total score
 score of ≥ 4 as neuropathic pain

17. Douleur Neuropathique en 4(DN 4) questions

18. 4. Pain detect:
Patient based self report questionnaire consisting of 9 items:
 7 sensory descriptions and
 2 related to spatial(radiating) and temporal characteristics.
 Sensory descriptions are scored on a scale of 0 (no) to 5(very
strongly)
 Radiating pain as 1(yes) or 0(no)
 Score ≥ 19 indicates neuropathic pain likely
≤ 12 unlikely neuropathic pain
Note –no clinical examination is needed.

19. Pain detect questionnaire:

20. 5. ID -Pain
 It is a self questionnaire consisting of 5 sensory
description and 1 item regarding pain located in the
joints.
 Higher scores indicates neuropathic pain
ID –pain
- Pins and needles - Electric shocks
- Hot/ burning -Numb
- Is the pain made worse with touch of clothing or bed
sheets?
- Is the pain limited to your joints?(-1)

22. C:Mode of onset and location
 Helps in finding out etiology of pain
D: Chronicity(duration and frequency)
 e.g. in migraine the unilateral pain is frequently
throbbing and may exist for hours to days
E:Provocative and relieving factors
 E.g.- leg and back pain due to spinal stenosis has a
characteristic pattern of worsening with walking or
standing.

23. F: Special character
 e.g. – cluster headache- pain is deep , boring,
wrenching, and severe in intensity
G: Timing of pain
 Pain and stiffness felt in morning hours for> hours- d/t
inflammatory arthropathy
 < half hour – degenerative arthropathy
H: Relation to posture
Eg. Pain on sitting cross legged –Piriformis syndrome

24. Other :
 Past history
 Personal history
 Family history
 Treatment history
 Ruling out red flags

25. Psychological assessment :
Patient in pain can have some psychological disorders
like anxiety or depression
 Tools available are:-
I. PHQ-9
II. Beck depression inventory(BDI)
III. Hamilton depression scale
IV. Hospital anxiety and depression scale(HADS)
V. Pain catastrophizing scale(PCS)
VI. The tampa scale of kinesophobia
Helps in assessing
personality disorder

27. Becks depression inventory:
 21 parameters and each are graded from 0 to 3 ,so total
score of -63
 Results –
1-10-normal
11-16-mild mood disturbance
17-20-borderline
21-30-moderate depression
31-40-severe depression
>40-extreme depression

28. Hamilton depression scale:-
17 parameters with score grade of 0 to 4
i.e. symptoms is absent ,mild , moderate, severe
Total score -54
Hospital anxiety and depression scale(HADS):-
 14 parameters
 2,4,6,8,11,12,14-anxiety
 1,3,5,7,9,10,13-depression
Results –
0-7- non case
8-10-borderline case
11 or above -case

29. Hamilton,s parameter:-

30. HADS parameters:-